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ORIGINAL ARTICLE
Year : 2013  |  Volume : 6  |  Issue : 2  |  Page : 165-169  

Evaluation of hypertensive retinopathy in patients of essential hypertension with high serum lipids


Department of Ophthalmology, Padmashree Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth Pimpri, Pune, India

Date of Web Publication10-Apr-2013

Correspondence Address:
Rajendra P Gupta
Dr. D. Y. Patil Medical College, Pimpri, Pune
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.110307

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  Abstract 

Purpose: To evaluate the role of hyperlipidemia on fundus changes in hypertensive patients and to correlate the above findings with components of lipid profile. Materials and Methods: A cross-sectional study was carried out in 100 patients who were diagnosed to have systemic hypertension. Patients suffering from diabetes, high myopia, patients with hazy ocular media, and other retinal vascular disorders were excluded from the study. A detailed evaluation of patients' hypertensive status was carried out by a physician after ruling out secondary causes of hypertension. Their detailed ophthalmological examination was carried out. All the patients were investigated for fasting serum lipid profile. Results: Out of the 100 patients with essential hypertension, 69 (69%) had retinopathy and the remaining 31 (31%) subjects having retinopathy were mainly concentrated in the 6 th decade (69.70%), increasing thereafter up to 83.78% who were over 60 years of age. This shows the increasing prevalence of hypertensive retinopathy with increasing age. No sex preponderance toward developing retinopathy was found in this study (o < 0.29). A positive correlation of hypertensive retinopathy was found with total cholesterol (P < 0.002), low-density lipoprotein (LDL)-cholesterol (P < 0.0001), Serum triglycerides (P < 0.01), and an low-density lipoprotein: high-density lipoprotein (LDL:HDL) ratio (P < 0.002). Conclusion: This study proved a definite association between serum lipid parameters and the prevalence of hypertensive retinopathy.

Keywords: Dyslipidemia, high-density lipoprotein, hypertensive retinopathy, Keith Wagner Barker classification, low-density lipoprotein


How to cite this article:
Gupta RP, Gupta S, Gahlot A, Sukharamwala D, Vashi J. Evaluation of hypertensive retinopathy in patients of essential hypertension with high serum lipids. Med J DY Patil Univ 2013;6:165-9

How to cite this URL:
Gupta RP, Gupta S, Gahlot A, Sukharamwala D, Vashi J. Evaluation of hypertensive retinopathy in patients of essential hypertension with high serum lipids. Med J DY Patil Univ [serial online] 2013 [cited 2023 Jun 9];6:165-9. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2013/6/2/165/110307


  Introduction Top


Elevated blood pressure is the most important public health problem in developing and developed countries. It is common, asymptomatic, readily detectable, usually treatable, and often leads to lethal complications if left untreated.

Hypertensive retinopathy is among the vascular complications of essential hypertension. It is known that the auto-regulation of retinal circulation fails as blood pressure increases beyond a critical limit. However, elevated blood pressure alone does not fully account for the extent of retinopathy. [1]

Dyslipidemia in hypertensive patients is itself known to be a predisposing risk factor, an aggravating or complicating factor. [2] Hypertension and hyperlipidemia not only accelerate atherogenesis but also cause degenerative changes in the walls of large- and medium-sized arteries, [3] which accelerate cerebrovascular hemorrhage, [4] ischemic heart disease, [5] stroke, and cardiac arrest. [6],[7],[8]

Hence, this study helps to assess the association between hypertensive retinopathy in patients of essential hypertension with an altered serum lipid profile, with the aim of preserving vision by tailoring a lipid-lowering treatment.


  Materials and Methods Top


A cross-sectional study was performed on 100 patients who were diagnosed to have essential hypertension by a physician after thorough evaluation. Patients suffering from diabetes, high myopia, patients with hazy ocular media in both eyes, and other retinal vascular disorders were excluded from the study. A detailed ophthalmological examination included best corrected visual acuity, anterior segment examination using slit lamp and posterior segment examination by slit lamp biomicroscopy using 90D, and indirect ophthalmoscopy followed by fundus photography [Figure 1], [Figure 2], [Figure 3]. Staging of hypertensive retinopathy was carried out using Modified Keith Wagner Barker Classification. [9] Patients were investigated for complete fasting serum lipid profile. After complete evaluation, patients were counseled and appropriate treatment reference was advised.
Figure 1: Grade II hypertensive retinopathy

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Figure 2: Grade III hypertensive retinopathy

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Figure 3: Grade IV hypertensive retinopathy

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For different groups and parameters, mean and standard deviations were calculated. Means of the relative groups were compared using Student's 't' tests. The Chi square test was used to identify the independence of the groups and the level of different parameters.


  Results Top


After satisfying the selection criteria, 100 patients were included in this study. Out of 100 patients, 31 patients had a normal fundus and 69 patients had retinopathy in both eyes. Each patient had retinopathy in both eyes of the same grade. The mean age, duration of hypertension, systolic BP, diastolic BP, total cholesterol, low-density lipoprotein (LDL)-cholesterol, serum trigylcerides, and the low-density lipoprotein:high-density lipoprotein (LDL:HDL) ratio were high compared with those who did not show any signs of retinopathy and the association was statistically significant. Only the mean fasting blood sugar level and serum HDL level associations were not statistically significant.

Among the 100 patients studied, 11 patients belong to the 31-40-year age group. Of these 05 (45.45%) had retinopathy whereas 06 (54.55%) did not. The next category consisting of 19 patients belong to the 41-50-year age group, of which 10 (52.63%) had retinopathy, whereas 09 (47.37%) showed no retinopathy. Another category consisted of 33 patients belonging to the 51-60-year age group, out of which 23 (69.70%) patients had retinopathy, whereas 10 (30.30%) patients had no retinopathy. In the last category, i.e. age above 60 years, there were 37 patients, of which 31 (83.78%) had retinopathy and 06 (16.22%) had no retinopathy. In our study, we found that hypertensive retinopathy increases significantly with increase in age as the Chi square value is equal to 9.073 with a 3 degree of freedom (P = 0.036). We also found that retinopathy increased significantly above 50 years of age.

There were 64 males and 36 females in our study group. Out of these, 47 (73.44%) males and 22 (61.11%) females had retinopathy, and 17 (26.56%) males and 14 (38.89%) females had no retinopathy.

Of the 100 patients, 47 patients had hypertension since 0-5 years. Of these, 18 (38.3%) had retinopathy of varying degrees, whereas 29 (61.7%) had no retinopathy. There were 28 patients who had hypertension since age 6-10 years, of which 26 (92.86%) patients had retinopathy, whereas 02 (7.14%) patients had no retinopathy. The next group of 18 patients had hypertension since age 10-15 years, and all these patients had retinopathy. Among the last group of seven patients who had hypertension since >15 years, all had retinopathy. Overall, the relationship between various grades of retinopathy and duration was statistically significant (P < 0.0001).

Out of the 100 patients, 71 had total serum cholesterol within normal limits (<200 mg/dl). Of these, 41 (57.7%) patients had retinopathy, whereas 30 (42.25%) patients had no retinopathy. The next group of 23 patients had total serum cholesterol between 200 and 239 mg/dl, which is considered to be borderline. Of these, 22 (95.65%) patients had retinopathy, whereas 1 (4.35%) patient had no retinopathy. The last group of six patients had serum total cholesterol levels of >240, which is considered to be abnormal. Of these, 6 (100%) patients had retinopathy. Overall, the increase in total serum cholesterol levels correlated well with the increasing severity of retinopathy (P < 0.0008) [Table 1].
Table 1: Relationship of grades of retinopathy with serum total cholesterol


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Out of the 100 patients studied, 62 (62%) had serum LDL-cholesterol levels of <130 mg/dl (normal). of these, 24 (38.7%) had no retinopathy, whereas 38 (61.29%) had retinopathy of varying grades. the next group of 15 (15%) had serum LDL-cholesterol levels between 130 and 159 mg/dl (borderline), of which 05 (33.3%) had no retinopathy, whereas 10 (66.67%) had retinopathy. the last group of 23 (23%) patients had serum LDL-cholesterol levels of >160 mg/dl (abnormal), of which 02 (8.70%) patients had no retinopathy, whereas 21 (91.30%) had retinopathy. Overall, the increasing level of serum LDL-cholesterol showed statistically significant correlation with the grades of hypertensive retinopathy (P < 0.0001) [Table 2].
Table 2: Relationship of serum low-density lipoprotein-cholesterol with grades of retinopathy


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Out of the 100 patients, only 1 (1%) patient had serum HDL-cholesterol levels of >60 mg/dl and had retinopathy. the next group of 75 patients had serum HDL-cholesterol levels in the range 36-60 mg/dl (borderline), of which 54 (72%) patients had retinopathy and 21 (28%) had no retinopathy. the last group of 24 patients had serum HDL-C levels of <35 mg/dl (abnormal), of which 14 (58.33%) patients had retinopathy, whereas 10 (41.67%) did not. Overall at 90%, the HDL levels were significantly lower in hypertensive retinopathy patients than in normal patients (P = 0.061) [Table 3].
Table 3: Relationship between serum high-density lipoprotein-cholesterol with grades of retinopathy


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Out of the 100 patients, 40 (40%) patients had an LDL:HDL ratio of <2.5, of which 25 (62.5%) had varying grades of retinopathy, whereas 15 (37.5%) had no retinopathy.

The next group of 45 (45%) patients had a serum LDL:HDL ratio of between 2.5 and 5.1. Of these, 29 (64.4%) had retinopathy, whereas 16 (35.56%) had no retinopathy. The last group of 15 (15%) patients had a serum LDL HDL-C ratio >5.00. Of these, 15 (100%) patients had retinopathy. Overall, the increasing levels of LDL:HDL-cholesterol correlated positively with increasing severity of retinopathies, which was statistically significant (P = 0.0001) [Table 4].
Table 4: Relationship between serum low-density lipoprotein and high-density lipoprotein ratio with grades of retinopathy


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Out of the 100 patients, 68 (68%) patients had serum triglyceride levels of <150 (normal), of which 42 (61.76%) patients had retinopathy, whereas 26 (38.24%) patients had no retinopathy. Of the remaining 32 (32%) patients who had serum triglyceride levels of >150 mg/dl, 27 (84.38%) patients had retinopathy, whereas 05 (15.63%) patients did not.

Overall, serum triglyceride levels correlated positively with the increasing severity of retinopathy, which was statistically significant (P = 0.01) [Table 5].
Table 5: Relationship of serum triglycerides with grades of retinopathy


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  Discussion Top


The mean age of patients in the present study population was 56.50 ± 21.00 years, ranging from 35 to 78 years. Out of these, 69 patients belonged to the retinopathy group with a mean age of 56.00 ± 17.00 years and 31 patients had normal fundus, with a mean age of 50.50 ± 15.0 years (P < 0.00l). in a study carried out by Bastola et al., [11] the mean age of the study group was 58.5 years (SD = 9.2 years; range = 33-48).

There were 64 males and 36 females in this study group, out of which 47 (73%) males and 22 (61.11%) females had retinopathy. Although 17 (27%) males and 14 (38.89%) females had no signs of retinopathy, there was no significant sex preponderance (P < 0.29). In the past, there have been fewer studies of the incidence of hypertensive retinopathy and none of them have shown sex preponderance.

In our study, there was an increased incidence of hypertensive retinopathy in patients having high serum cholesterol level and this association was statistically significant (P < 0.0008). Similarly, Bastola et al., [11] in their study, also showed that there was a statistically significant difference in the mean serum cholesterol level (F = 10.38; P < 0.001) of patients with normal fundus and in those with different grades of hypertensive retinopathy. In general, the association of serum total cholesterol levels was highly significant (P < 0.0008). Similarly, we found a significant association between serum LDL-cholesterol and the severity of the retinopathy (P < 0.0001).

Badhu et al. also assessed the serum level of LDL in hypertensive retinopathy. Their results showed a statistically significant (P < 0.0196) higher serum level of LDL-cholesterol in hypertensive patients with retinopathy (mean ± SD = 2.45 ± 1.76 mmol/l, SE = 0.33 and 95% CI = 1.79-3.11 vs. mean ± SD = 1.6 ± 0.4 mmol/l, SE = 0.08 and 95% CI = 1.44-1.76). The study concluded that an increased serum level of LDL-cholesterol is associated with a higher incidence of hypertensive retinopathy, [12] which corroborates with our findings. Bastola et al. [11] also showed a significant correlation between serum LDL-cholesterol and grade II and higher hypertensive retinopathy (F = 30.39; P < 0.001).

The mean serum HDL-cholesterol value for the retinopathy group was 38.68 and that for the no retinopathy group was 39. There was no significant association between serum HDL-cholesterol and retinopathy. Bastola et al. [11] also showed similar findings. No other study has reported any correlation between serum HDL-cholesterol and hypertensive retinopathy so far.

The association of LDL:HDL-cholesterol ratio was found to be statistically significant (P < 0.0001). In the literature, no such correlation has been reported so far.

We found a significant association between serum triglycerides and hypertensive retinopathy patients (P < 0.01). Mean triglycerides levels were also found to be high in grade II and higher hypertensive retinopathy patients in a study carried out by Bastola et al. [11]

Thus, this study shows a definite association between serum lipid parameters and the prevalence of hypertensive retinopathy.


  Conclusion Top


Hypertensive retinopathy has been found to occur in people above 35 years of age, with a mean age of 56 years. There was no sex preponderance. There was an increase in incidence of hypertensive retinopathy with increase of serum total cholesterol, serum LDL, and serum triglycerides. However, no correlation was found between HDL-cholesterol and hypertensive retinopathy.

 
  References Top

1.Liebreich R. Bright's disease at diagnosis-shear ophthalmoscopy Albercht Von Graefes. Arch Ophthalmol 859;5:265-8.  Back to cited text no. 1
    
2.Thakur AK, Achari V. A study of lipid levels in uncomplicated hypertension. Indian Heart J 2000;52:173-7.  Back to cited text no. 2
    
3.Naomi DL, Gordon HW. Hypertensive Vascular Disease. In: Fisher ND, Williams GH, editors. Harrison's Principles of Internal Medicine. 16 th Ed. New York: McGraw Hill; 2005. p. 1463-70  Back to cited text no. 3
    
4.Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation 1998;97:1837-47.  Back to cited text no. 4
    
5.Law MR, Wald NJ, Thompson SG. By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ 1994;308:367-72.  Back to cited text no. 5
    
6.Prospective studies collaboration, Cholesterol, diastolic blood pressure, and stroke: 13,000 strokes in 450,000 people in 45 prospective cohorts. Lancet 1995;346:1647-53.  Back to cited text no. 6
    
7.Hachinski V, Graffagnino C, Beaudry M, Bernier G, Buck C, Donner A, et al. Lipids and stroke: A paradox resolved. Arch Neurol 1996;53:303-8.  Back to cited text no. 7
    
8.Duncan BB, Wong TY, Tyroler HA, Davis CE, Fuchs FD. Hypertensive retinopathy and incident coronary heart disease in high risk men. Br J Ophthalmol 2002;86:1002-6.  Back to cited text no. 8
    
9.Walsh JB. Hypertensive retinopathy. Description, classification, and prognosis. Ophthalmology 1982;89:1127-31.  Back to cited text no. 9
    
10.Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-97.  Back to cited text no. 10
    
11.Bastola P, Pun CB, Koirala S, Shrestha UK. Fasting serum lipids and fundus changes in hypertensive patients. Nepal J Med Sci 2012;1:103-7.  Back to cited text no. 11
    
12.Badhu B, Dulal S, Baral N, Lamsal M, Shrestha JK, Koirala S. Serum level of low-density lipoprotein cholesterol in hypertensive retinopathy. Southeast Asian J Trop Med Public Health 2003;34:199-201.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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